Active NPI
Susada Inthavong, APRN
- Nurse Practitioner
- South Windsor, CT
National Provider Identifier
1275770398
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Nurse Practitioner
- License
- 003968
- Practice address
- 1504 Sullivan Ave
South Windsor, CT 06074-2711 - Phone
- (860) 644-1523
- Fax
- (860) 648-9468
- NPI assigned
- Jan 12, 2009
- Last updated
- Jan 12, 2009
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nurse Practitioner | 363L00000X | 003968 | CT | Primary |
Addresses
Primary practice location
1504 Sullivan Ave
South Windsor, CT 06074-2711
Mailing address
29 Naek Rd
Suite 5
Vernon, CT 06066-3942
Phone (860) 872-2289
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 003968 | Other | CT | STATE LICENSE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3968 | CT | MD | Clinical Psychologist |
| 003968 | CT | MD | Physical Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Prospect CT Medical Foundation, Inc. | Nurse Practitioner | Past | Accepting new patients |
| Harold E Beam | Past | Accepting new patients | |
| Healthwise Medical Associates, LLP | Past | Accepting new patients |
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
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Nurse Practitioner
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1231718400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1231718400000",
"number": "1275770398",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "29 NAEK RD",
"address_2": "SUITE 5",
"city": "VERNON",
"state": "CT",
"postal_code": "060663942",
"telephone_number": "860-872-2289",
"fax_number": "860-896-1425"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1504 SULLIVAN AVE",
"city": "SOUTH WINDSOR",
"state": "CT",
"postal_code": "060742711",
"telephone_number": "860-644-1523",
"fax_number": "860-648-9468"
}
],
"practiceLocations": [],
"basic": {
"last_name": "INTHAVONG",
"first_name": "SUSADA",
"credential": "APRN",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2009-01-12",
"last_updated": "2009-01-12",
"status": "A"
},
"taxonomies": [
{
"code": "363L00000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner",
"state": "CT",
"license": "003968",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE LICENSE",
"identifier": "003968",
"state": "CT"
}
],
"endpoints": [],
"other_names": []
}Other providers in South Windsor, CT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 12, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.